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Liver transplantation in Eastern countries
C. Broelsch (Chirurgia, 100 (1): 11-12)
During the last decade liver transplantation has received an enormous attention in countries where medical standards have been improved through international conferences, special fellowships and institutional upgradings. In Eastern European countries, the political changes lead to a steady upheaval in economic welfare and thus in medical care. The new openness of the societies, the availability of medical literature, and the practical exchange of medical and surgical knowledge form the basis for further progress in many medical specialties. One of the most exciting and promising endeavours is going to be organ transplantation and within this context liver transplantation! However, since liver transplantation is the most demanding procedure ever to be performed on a human being, its implementation requires a new level of logistics, skills and personal commitments.
The grounds for liver transplantation have been laid for 20 years in the Western world, when liver transplantation has been established as a clinical modality for treatment of end stage liver diseases. During 1983, the National Institute of Health, Consensus Conference compiled the results of 4 major centers (1). More than 300 patients were accumulated to establish a consensus for the future of liver transplantation. By then, the United States Center of Denver/Pittsburgh (Dr. Thomas E. Starzl), the UK-Center of Cambridge (Sir Roy Cale), the German Center at the Medical School Hannover (Prof. Dr. Rudolph Pichlmayr), and the Dutch Center of the University of Groningen (Dr. Ruud Krom) demonstrated the feasibility and efficacy of this complex procedure.
It needs to remember that already in the 60s several attempts of performing human liver transplantations have failed, although extensive laboratory and experimental animal work was published.
Finally, during the 70s, the enduring courage and perseverance of leading visionary surgeons, in particular Dr. Thomas Starzl were gratified with lasting success rates (2). By then, a number of younger surgeons devoted their professional careers into this new field: surgeons like Ron Busuttil (Los Angeles), Göran Klintmalm (Baylor College Texas), Bud Shaw (Pittsburgh/Omaha, USA), Henry Bismuth and Didier Houssin (Hopital Brousse, Paris/ France), Carl Groth (Karolinska Institute Stockholm) and myself, University of Chicago/USA and later Essen/ Germany. Even the junior generation has come of age and already the next generations within more than 300 transplant centers around the world are now performing liver transplantations with success rates similar to kidney and heart transplantations.
It is imperative that the lessons from the past are being observed which include more training of a surgical team into the task of liver transplantation. What has once been a heroic operation performed on desperate patients, has become an exemplary team approach by surgeons, anaesthesiologists, hepatologists, nephrologists, virologists, immunologists, haematologists and transplant coordinators.
The development of an organ procurement system for procuring cadaveric organs within the framework of legislation, public awareness and acceptance of altruistic organ donation have now made transplantation available on a large scale - at least in Western countries! However, the availability of brain dead, cadaveric donors is now the limiting factor for the expansion and application of liver transplantation and of organ transplantation in general! All Western countries, irrespective of their legislation, do not provide efficient numbers of organs for the need of their citizens. Each political system thus far has failed to provide this availability, although a vast majority of the people in each country would be willing to donate and accept transplant organs. Key issues still evolve around the acceptance of brain death or the pronounciation of the death of an individual. Hence, in addition brain death identification demands a substantial effort of physicians and medical personnel, who are not involved in organ transplantation at all. It is imperative, that their understanding for organ donation and in particular for the need of patients, beyond their own regular medical practice is being awakened. Without their support, organ transplantation would be limited to a small number of patients who can provide a life donor from within their family and social environment.
The life donor organ procurement for kidney transplantation has been established since the first successful kidney transplantation by the Nobel laureate Dr. J. Murray of Boston in 1954 (3). During the last year, live kidney donation in the United States has exceeded the number of cadaveric donors raising an ethical issue to what extent a live donor can be motivated for donating a kidney as to whether the public legislation can be changed to make organ donation a mandatory donation upon death.
Since mandatory legislation does not seem to be implicable, efforts are being made to provide incentives for families and live donors to donate.
Due to the lack of an appropriate organ procurement system, many centers now have embarked on the performance of live organ donation and have prepared themselves as well as institutions for the performance of such an operation. Since the first successful series of liver transplantations from live donors in 1989 at the University of Chicago (4), living related liver transplantation has now been performed in several thousand cases around the world. The enormous skills of individual transplant surgeons, obtained during fellowships in practical exposure in major transplant centers have created new centers of excellence for liver transplantations. Particularly in Japan, where brain death is legally accepted but practically not applied, living related liver transplantation has become publicly more accepted than cadaveric organ donation and has made the Japanese center in Kyoto (Professor Tanaka) (5) and Tokyo (Professor Makuuchi) (6) the most experienced centers in the world. They and others have taken on the task to teach other centers the performance of live donor liver transplantation and thus have secured the surgeon's responsibility for the well being of the donor.
While public awareness for organ donation is still being underdeveloped, centers in Eastern European countries have assembled their teams to perform liver transplantations from live donors as well. It reflects upon the responsibility of the surgical leaders that they have asked and are being supported by experienced teams until they work independently. For experienced teams it is a unique opportunity to share their experiences with upstarting centers. The Fundeni University of Bucharest (Professor Popescu, Romania) and his teams have taken enormous efforts to guide their associates and medical personnel as well as their institutions into the task of liver transplantation. They have assembled a core team of anaesthesiologists, Radiologists and Hepatologists to direct their efforts into the treatment of otherwise fatal liver diseases. For medical and economical reasons, their patients do not have alternatives and thus they may take an initially higher risk as compared to Western patients. However, the Japanese experiences show that in an environment of committed surgeons, anaesthesiologists and intensivists and other specialists including the administration of an institution and eventually the government, liver transplantation has become reality in a world that was historically excluded from progress. It is with excitement, joy and satisfaction to see how these centers grow and develop providing medical knowledge and services in a field, which was previously non-existent. Results, complications, successes as well as failures need to be reported, discussed and eliminated in the future. This is the only way medical progress will convince their society of the value of transplantation. As Shakespeare once said: "Desperate diseases by desperate appliances are relieved or not at all! The Romanian Program of the Fundeni University will inevitably succeed!

References
1. NATIONAL INSTITUTES OF HEALTH CONSENSUS DEVELOPMENT CONFERENCE STATEMENT - Liver Transplantation, June 20-23, 1983. Hepatology, 1984, 4:107.
2. STARZL, T.E., BRETTSCNEIDER, L., GROTH, C.G. - Liver Transplantation. Bull. Soc. Int. Chir., 1967, 26:474.
3. MERRILL, J.P., MURRAY, J.E., HARRISON, J.H., GUILD, W.R. - Successful homotransplantation of the human kidney between identical twins. J. Am. Med. Assoc., 1956, 160:277.
4. BROELSCH, C.E., WHITINGTON, P.F., EMOND, J.C., HEFFRON, T.G., THISTLETHWAITE, J.R., STEVENS, L., PIPER, J., WHITINGTON, S.H., LICHTOR, J.L. - Liver transplantation in children from living related donors. Surgical techniques and results. Ann. Surg., 1991, 214:428.
5. TANAKA, K., KIUCHI, T., KAIHARA, S. - Living related liver donor transplantation: techniques and caution. Surg. Clin. North Am., 2004, 84:481.
6. MAKUUCHI, M., KAWARZAKI, H., IWANAKA, T., KAMADA, N., TAKAYAMA, T. KUMON, M. - Living related liver transplantation. Surg. Today, 1992, 22:297.

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